In-hospital cardiac arrest: evidence and specificities of perioperative cardiac arrest

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To the Editor,
We read with great interest the article by Penketh and Nolan, which provides a comprehensive overview on inhospital cardiac arrest (IHCA) [1]. We fully concur with the authors that guidelines for treatment of IHCA are lacking, and that several data are extrapolated from outof-hospital cardiac arrest literature. Despite the extensive evidence from rigorous randomized controlled trials, professional guidelines reflect little tangible progress and a main contributing factor is the stagnation of resuscitation science due to our poor knowledge of the underlying pathophysiological mechanisms [2].
Regarding IHCA, this disheartening situation is more evident during the perioperative period as guidelines for treatment of perioperative cardiac arrest have been for long a major gap of knowledge. However, perioperative cardiac arrest has several specificities that are not detailed in Penketh's review and that deserve considerations: potential neuroprotective effect of anesthesia drugs, immediate diagnosis in monitored patients, timely treatment by trained anesthesiologists, causes of cardiac arrest mostly related to preoperative complications, complications of anesthesia or complications of surgical procedures and finally, good long-term functional outcome [3].
In order to provide a scientific background for decision-making, as well as a guide for future research on perioperative cardiac arrest, the PERIOPCA Consortium recently published for the first time a consensus on 22 PICO questions specially formulated for the perioperative setting [4]. These recommendations (Table 1) are strengthened by a strict methodology including a modified Delphi consensus-building strategy and can be used in clinical practice.
Fortunately, the perioperative setting supports a physiology-guided treatment strategy to titrate the resuscitation efforts to patient's physiological response. Therefore, translational research should be intensively used as a bridge between different areas of research to improve survival rates. Such an approach is currently investigated in the PERSEUS-PS randomized controlled trial (NCT04428060) [5].
We hope that the PERIOPCA recommendations and the results of the PERSEUS-PS trial will serve as a basis and would be of interest for the International Liaison Committee on Resuscitation or the scientist who wants to build upon the available evidence. Monitoring physiological parameters during CPR In adults with cardiac arrest in the perioperative setting, the use of physiological feedback may be reasonable to increase CPR quality and improve short-and long-term outcome (COR/ Cardiac arrest associated with pulmonary embolism In adult patients with PERIOPCA due to pulmonary embolism or suspected pulmonary embolism, early consideration of thrombolysis and CPR duration of at least 60-90 min with or without the use of a mechanical chest compression device may be reasonable before terminating resuscitation attempts (COR/LOE: IIb/C-LD). The emergency treatment option among fibrinolytic therapy, surgical, or mechanical thrombectomy should be selected based on timing and available expertise, since no clear benefit of one approach over the other has been demonstrated Cardiac arrest during pregnancy In pregnant women with PERIOPCA, the effectiveness of any special interventions, compared to standard measures, is uncertain, except probably for manual uterine displacement during chest compressions (COR/ LOE: IIb/C-EO). In pregnant women with PERIOPCA due to suspected or proven pulmonary embolism, it may be reasonable to use thrombolysis or other measures to remove clot (e.g., surgical or percutaneous pulmonary embolectomy) (COR/LOE: IIb/C-EO). Extracorporeal membrane oxygenation may be considered as an acceptable salvage therapy for pregnant and postpartum patients with PERIOPCA or those with critical cardiac or pulmonary illness (COR/LOE: IIb/C-EO) Opioid toxicity In patients with PERIOPCA due to opioid toxicity, it might be reasonable to administer specific agents in addition to advanced life support (COR/LOE: IIb/C-EO) Epinephrine, vasopressin, steroids, and their combination during or after CPR In adult patients with PERIOPCA, it is reasonable to administer corticosteroid or mineralocorticoid or the combination of vasopressin, epinephrine, and steroids during/after CPR to increase ROSC (COR/LOE: IIa/B-R). In these patients, these drugs can be useful for improving survival to discharge with good functional outcome (COR/LOE: IIa/B-R) Lipid therapy for cardiac arrest In adult patients with PERIOPCA due to confirmed or suspected LAST, it may be reasonable to use lipid therapy (COR/LOE: IIb/C-LD) Ultrasound during CPR In patients with PERIOPCA, it may be reasonable to use point-of-care ultrasound to improve CPR and increase survival rates (COR/LOE: IIb/C-EO) In patients with PERIOPCA and ROSC, it may be reasonable to use a multimodal strategy for prognostication, giving emphasis on allowing sufficient time for neurological recovery and to enable sedatives/paralytics to be cleared (COR/LOE: IIb/C-EO) PERIOPCA perioperative cardiac arrest, CPR cardio-pulmonary resuscitation, ECPR extracorporeal cardio-pulmonary resuscitation, ROSC return of spontaneous circulation, COR class of recommendation, EO expert opinion, LD limited data, LOE level of evidence